Although a woman's ability to become pregnant spans almost half her lifetime, American women today typically want only two children—a goal that, for most, is unrealistic without contraception. One of the United States' key public health goals has long been to expand access to contraceptive services to all those who need and want them, with a special emphasis on reaching those traditionally hindered in their attempts to obtain care by income or other factors, such as age or geography. This Issues in Brief examines the 30-year record of the nation's voluntary family planning effort, outlining its origins, describing its current structure and funding, and assessing the impact it has had in preventing unintended pregnancies, births and abortions.
Origins of the Program
Studies conducted during the 1960s showed that rates of
unwanted childbearing among low-income women were at least twice as high
as those among the more affluent—a phenomenon traceable in large part
to inequalities in access to family planning services. By the end of the
decade, a sizable, bipartisan consensus had emerged favoring government
support of voluntary family planning programs as a means of expanding
economic development, alleviating poverty, avoiding welfare dependency and
improving the health of women and their families.
Even as this consensus was forming, Congress amended a number of federal laws to allow family planning services to be provided under existing programs. In 1965, as part of the "War on Poverty," federal funds were made available for family planning through the Office of Economic Opportunity. In 1967, Title IV-A of the Social Security Act was amended to require state welfare agencies to offer and provide family planning services to women receiving public assistance.
Then, in 1970, with broad bipartisan support, legislation establishing Title X of the Public Health Service Act was signed into law by President Richard Nixon, creating for the first time a comprehensive federal program devoted entirely to the provision of family planning services on a national basis. The new program sought to fulfill the president's promise that "no American woman should be denied access to family planning assistance because of her economic condition."
Public expenditures for family planning grew rapidly in the early 1970s, as the clinics Title X helped to create became established across the country. In 1972, in recognition of disparities in services across states, Congress amended the Medic-aid statute (Title XIX of the Social Security Act) to mandate inclusion of family planning services in all state Medicaid programs. By the early 1980s, almost $340 million in federal and state funds was being spent to provide family planning services to five million women at nearly 5,200 service sites.
Since then, however, a persistent combination of conservative politics and fiscal pressures has forced family planning clinics to confront both budget cuts and new administrative restrictions. Despite these ongoing struggles, publicly funded agencies continue to provide services to large numbers of low- and moderate-income women and teenagers.
Sources of Funding
Public funds to provide family planning services come from diverse programs with different focuses (see Chart A). The largest source of funding is the federal-state Medicaid program. While
nine in 10 family planning agencies derive at least some income from
Medicaid reimbursement, few rely heavily on it. Medicaid does not fund
family planning clinics or provide services directly. Instead, it is an
insurance mechanism whereby federal and state governments reimburse
physicians and other health care professionals for the medical services,
including family planning, they have provided to eligible
individuals.
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Several public programs fund contraceptive services.
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Many poor women are not eligible for Medicaid coverage. To qualify in most states, a woman must be single, already have a child (or be pregnant) and have an income below state requirements; nationwide, the average income eligibility ceiling is only about 46% of the federal poverty level, or approximately $6,100 a year for a family of three.
Most poor and low-income women who do not qualify for Medicaid are dependent on publicly funded clinics for help in obtaining family planning services. The establishment and operation of these clinics is accomplished through Title X, the only federal program dedicated solely to funding family planning and related reproductive health care services. Clinic services are also partially supported in most states with federal funds from the maternal and child health block grant and the social services block grant (Titles V and XX of the Social Security Act, respectively), but with a few exceptions, family planning services are only a small component of these broad programs.
Finally, state contributions to family planning services have grown considerably since the 1970s; 68% of family planning agencies received some support from state and local sources in 1995. Although 10 states provided no state funds for family planning services in 1994, some of these allocated significant proportions of their federal block-grant allotments for this purpose.
Who Provides Services?
In 1994, a total of 3,119 agencies provided organized family planning services—1,413 health departments, 159 Planned Parenthood affiliates, 534 hospitals and 1,013 other types of
agencies. Together, these agencies operated 7,122 clinic sites. Of these,
44% were operated by state health departments, 13% by Planned Parenthood
affiliates, 11% by hospitals and 32% by other agencies, such as
independent family planning councils and community and migrant health
centers.
Each clinic site served an average of 923 clients in 1994. Planned Parenthood affiliates reported serving 2,074 clients per clinic, while health department clinics, many of which are located in rural or sparsely populated areas, served an average of 681 clients annually. In the aggregate, however, both types of agencies served about the same proportion of all family planning clinic clients—30% and 32%, respectively.
Who Receives Services?
According to 1994 data, an estimated 6.6 million women receive contraceptive services annually
through the network of publicly subsidized family planning providers.
Overall, 30% of these clients are younger than 20, 50% are aged 20-29
and 20% are aged 30 or older. A majority of the contraceptive clients
served at publicly funded agencies are non-Hispanic whites (61%), while
14% are Hispanics, 19% are blacks and 7% are Asians or of some other race.
Most of the clients are poor—57% have family incomes that are below
the federal poverty level, and one-third have family incomes of
100-250% of poverty. How-ever, only one-quarter of all clients are
Medicaid recipients.
While the reach of the family planning clinic network is encouraging, weaknesses in the provision of services remain. One indicator of the continuing need is shown by a 1995 National Center for Health Statistics report that U.S. women have an average of 3.3 pregnancies over their lifetimes, of which only 1.8 are wanted births. According to the report, white women average 2.8 pregnancies, 1.6 of which are wanted births; black women average 5.1 pregnancies, of which 1.8 are wanted births; and Hispanic women average 4.7 pregnancies, of which 2.6 are wanted births.1
Services Provided
Family planning agencies provide a
variety of contraceptive options—usually at lower cost than available
elsewhere—along with the information and education that clients need
to choose the best method for their needs. Oral contraceptives are
universally available at family planning agencies, but the provision of
other methods varies depending upon the type of agency. Planned Parenthood
affiliates offer an average of 10 methods, while health departments and
community and migrant health centers offer seven contraceptive methods, on
average.
Depo-Provera, a hormonal injection that was approved for use in the United States in 1992, is now available from 96% of family planning agencies. Additional methods offered by 90% of agencies include male condoms, spermicides and the diaphragm. Some three-quarters of all agencies also offer natural family planning (periodic abstinence). Norplant is offered by 59% of agencies; the remaining six methods—the IUD, postcoital hormonal pills (emergency contraception), female condom, cervical cap, tubal ligation and vasectomy—are offered by fewer than 50% of agencies.
Besides providing contraceptive methods and related counseling, family planning clinics offer many other reproductive health services. All agencies routinely provide Pap tests, breast and pelvic exams and blood pressure measurement in the course of a woman's contraceptive visit. In addition, the vast majority of agencies provide such services as prenatal, postpartum and well-baby care; immunizations; and services under the Special Supplemental Food Program for Women, Infants and Children (WIC).
It is the policy at 94% of agencies to routinely obtain clients' sexual histories, and three-quarters of agencies routinely test for anemia. Testing for sexually transmitted diseases (STDs), urinary tract infections or pregnancy are routinely provided at some agencies; more often, however, these tests are provided only on indication or if the client requests to be tested. Routine testing for three STDs—gonorrhea, chlamydia and syphilis—is provided by 64%, 54% and 42% of agencies, respectively.
In addition, 96% of agencies routinely counsel clients regarding the risk factors for STDs and the human immunodeficiency virus, and 62% routinely provide education related to condom negotiation skills. All agencies report providing contraceptive education through individual counseling and the distribution of printed materials, and nearly nine in 10 encourage counselors to spend more time with teenagers than with other clients.
The Impact of Services
Publicly funded family planning services have been responsible for preventing large numbers of unintended
pregnancies, abortions and births among low-income women, especially
unmarried women and teenagers.
The data also show that public funding of family planning services prevents poor birth outcomes and improves women's overall health.
The benefits of publicly funded family planning services in the United States have long been recognized. Authorities in public health have agreed on family planning's effectiveness, not only in preventing unintended pregnancies but also in improving the health of women and children (see box, Family Planning Benefits, below).
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The Key Role of Title X
While no longer the largest funder
of family planning services, the Title X program continues to be the glue
that holds the national family planning system together, largely
determining both its structure—through the nationwide network of
clinics—and the substance of services that are provided to low- and
moderate-income women and teenagers. In 1994, 4.2 million family planning
clients were served by clinics administered by Title X-supported
agencies.
Because of the availability of subsidized family planning services, many women do not have to face decisions regarding an unintended pregnancy. In 1994, nearly one million unintended pregnancies were averted among women who attended Title X-funded clinics (see Table 1).
| State | Clients served (1994) |
Pregnancies averted |
| U.S. | 4,156,850 | 969,700 |
| AL | 89,430 | 20,900 |
| AK | 6,690 | 1,600 |
| AZ | 33,330 | 7,800 |
| AR | 73,510 | 17,100 |
| CA | 501,080 | 116,900 |
| CO | 50,630 | 11,800 |
| CT | 49,810 | 11,600 |
| DE | 14,790 | 3,500 |
| DC | 14,540 | 3,400 |
| FL | 168,640 | 39,300 |
| GA | 169,880 | 39,600 |
| HI | 17,480 | 4,100 |
| ID | 29,590 | 6,900 |
| IL | 162,670 | 37,900 |
| IN | 77,750 | 18,100 |
| IA | 74,160 | 17,300 |
| KS | 47,720 | 11,100 |
| KY | 114,470 | 26,700 |
| LA | 58,510 | 13,600 |
| ME | 35,510 | 8,300 |
| MD | 72,210 | 16,800 |
| MA | 70,530 | 16,500 |
| MI | 127,170 | 29,700 |
| MN | 36,520 | 8,500 |
| MS | 78,920 | 18,400 |
| MO | 93,500 | 21,800 |
| MT | 28,380 | 6,600 |
| NE | 27,110 | 6,300 |
| NV | 17,400 | 4,100 |
| NH | 31,730 | 7,400 |
| NJ | 102,010 | 23,800 |
| NM | 40,170 | 9,400 |
| NY | 237,670 | 55,400 |
| NC | 112,680 | 26,300 |
| ND | 14,250 | 3,300 |
| OH | 141,290 | 33,000 |
| OK | 53,620 | 12,500 |
| OR | 35,130 | 8,200 |
| PA | 262,190 | 61,200 |
| RI | 13,150 | 3,100 |
| SC | 65,810 | 15,400 |
| SD | 17,070 | 4,000 |
| TN | 101,810 | 23,800 |
| TX | 233,300 | 54,400 |
| UT | 15,430 | 3,600 |
| VT | 9,240 | 2,200 |
| VA | 79,130 | 18,500 |
| WA | 88,290 | 20,600 |
| WV | 70,820 | 16,500 |
| WI | 79,050 | 18,400 |
| WY | 11,080 | 2,600 |
Title X is administered by the Department of Health and Human Services (DHHS), which is responsible for allocating among the 10 federal health regions the funds appropriated annually by Congress. The federal health administrator in each region receives applications from, and awards grants on a competitive basis to, public agencies and private nonprofit agencies that provide contraceptive services as well as training, technical assistance and other support.
In 1994, a total of 85 primary grantees (1-6 per state) received Title X support. Fifty-one of these were state, territorial, local or municipal health departments; 14 were independent family planning councils (regional, nonprofit umbrella agencies); seven were Planned Parenthood affiliates; and 13 were other types of community agencies, such as hospitals.
Some Title X grantees operate family planning clinics directly, distributing grant funds among their various facilities. Others allocate the money to "delegate agencies," which operate individual clinics. Agencies providing family planning services, whether primary Title X grantees or their delegates, are diverse, community-based organizations. They include university medical centers, community action organizations, community health centers, nursing service organizations and a wide variety of nonprofit agencies, many of which are located in places where little or no other reproductive health care is available.
In 1994, nearly two-thirds of all women served by family planning clinics, 4.2 million women, obtained care at one of the 4,200 clinics receiving Title X funds. Health department sites were the most likely to receive Title X funding (78%), followed by independent clinics and Planned Parenthood sites (66% each), hospital clinics (28%) and community and migrant health centers (18%). Overall, clinics receiving Title X funds served at least 25% more clients per site than those that did not. In addition, because Title X funding is not tied to specific medical services for specific eligible clients, the agencies that received this funding were able to serve more uninsured, near-poor clients, more adolescents and more members of other special populations than were clinics that did not receive these funds.
Title X also determines the substance of the services offered to individuals. Each grantee is ultimately responsible for ensuring that its delegate agencies and the clinics they run meet the program's requirements. The law establishes a broad definition of family planning and sets standards for reproductive health care with which all providers receiving any Title X funds must comply. The Title X regulations and official program guidelines outline in great detail protocols for the provision of family planning services that comport with nationally recognized medical standards, including a mandate that patients at clinics supported by Title X be offered—on a purely voluntary, confidential basis—the full range of contraceptive methods and related counseling.
Any woman, regardless of her age, marital status or childbearing experience, may go to a Title X-funded clinic for family planning services. However, the amount each individual pays for the services she receives depends on her income. If she is very poor (her income is at or below 100% of the federal poverty level), the law requires that she receive fully subsidized services. If her income is above 250% of poverty, she must pay the full fee charged by the clinic, and if it falls in between, she must be charged for services on a sliding-fee scale.
The Title X program also supports three functions aimed at assisting clinics to respond to clients' changing needs. To foster consistently high standards in the delivery of family planning services, Title X supports centralized training in each of the 10 federal health regions and is a major source of funding for five of the nation's accredited nurse practitioner training programs. Title X specifically authorizes research to improve the delivery and efficiency of family planning services nationwide. Third, Title X requires that information be collected on the program and its clients and provided periodically to Congress.
Title X and Politics
As the one federal program devoted to
the provision of family planning services, Title X has been the focal
point for much of the political wrangling over reproductive health issues.
Eliminating Title X. In 1995, Rep. Bob Livingston (R-LA) proposed eliminating the Title X program and reallocating its funds to the maternal and child health block grant and community and migrant health centers—without requiring that any of the reapportioned funds be spent to provide family planning services. He and his supporters argued that Title X should be turned over to the states to permit maximum flexibility in the provision of health care services, reviving the long-standing debate over whether responsibility for the nation's social programs should rest with the federal government or the states.
Opponents of the Livingston amendment maintained that states wishing to administer the Title X program are already free to do so under the law and that passage of the amendment would jeopardize the existing network of clinics; the 25% of U.S. counties dependent solely on family planning service providers supported by Title X would be at risk of losing their family planning providers. Moreover, because of restrictions in the maternal and child health law, 30% of the funds at most could be spent to provide family planning. In the end, the House chose to maintain Title X as a discrete health program, defeating the Livingston amendment by a vote of 221-207.
Title X and Teenagers. From its inception, Title X has required that services be made available without regard to age or marital status. Consequently, Title X-supported clinics have always provided confidential services to adolescents who request them.
This fundamental underpinning of the program was challenged in 1996, when Rep. Ernest Istook (R-OK) offered an amendment that would have required family planning providers to obtain written parental consent for most minors seeking services at Title X-funded clinics.
The issue of adolescents' ability to consent to their own health care had not been confronted to such an extent since the Reagan administration proposed new Title X regulations in 1982, which were popularly known as the "squeal rule." While citing as its legal basis a congressional mandate from the previous year that Title X-funded clinics "to the extent practicable...encourage family participation" in minors' family planning decisionmaking, the squeal rule would have gone further to require clinics to notify parents by registered mail of their children's visit to a family planning clinic. Although more than 40,000 letters of protest were filed with DHHS from medical, health and civic groups, the regulations were finalized in 1983. But two federal appeals court judges eventually barred enforcement, and the regulations were withdrawn before going into effect.
Proponents of the 1996 Istook amendment stated their objections to the use of federal tax dollars to fund contraceptives for their children without their knowledge. In response, the amendment's opponents pointed out that the majority of teenagers do not come to family planning clinics until they have already been sexually active for at least a year, and that creating additional delays could discourage adolescents who are trying to take responsibility for their lives by protecting themselves against unintended pregnancies and STDs. In the end, a substitute amendment requiring Title X grantees to certify to the DHHS secretary that they encourage family participation in line with their long-standing mandate to do so prevailed by a vote of 232-193.
Title X and Abortion. From the beginning, the Title X statute has prohibited use of the program's funds for "abortion as a method of family planning." Congressionally requested investigations in the 1980s repeatedly found that all Title X-supported clinics were operating in full compliance with the law.
However, counseling regarding the management of an unintended pregnancy and referrals for requested medical and social services not offered by Title X are standard practice and are required by the program's guidelines. Nonetheless, in 1987, President Ronald Reagan ordered DHHS to promulgate new regulations that would have prohibited doctors and other health care professionals working in Title X-funded clinics from providing any abortion-related information or referrals.
The regulations generated more than 75,000 comment letters. Thirty-six state governments and a host of national health, medical and civic groups wrote in opposition to the proposed rules, expressing concern that withholding this information would violate their medical ethics and standards. Moreover, they pointed out, many of the women who depend upon Title X services often have no other source for this information.
While the legality of the so-called "gag rule" was upheld by the U.S. Supreme Court in 1991, Congress later passed legislation to overturn it. President George Bush vetoed the legislation, but a series of last-minute court orders blocked the regulations' enforcement. They were ultimately withdrawn in 1993 at the direction of President Bill Clinton.
Looking Ahead
Over the last decade or so, the proportion of public funding for family planning services from different sources has
shifted greatly. Of the $715 million spent by all public
sources—federal and state—to provide contraceptive services in
1994, $332 million, or 46%, was spent under Medicaid. In contrast, the
Title X program, through which $151 million was spent for contraceptive
services, accounted for only 21%.
In constant dollars—that is, dollars adjusted for inflation—Title X expenditures for contraceptive services decreased by 65% between 1980 and 1994. Despite a 70% increase in Medicaid, total public expenditures for contraceptive services dropped by 27% during that period (see Chart B).
Spending for family planning, in constant 1980 dollars, is down.
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At the same time, the cost of providing certain family planning services, such as contraceptive supplies and related laboratory expenses, appears to have risen: Between 1991 and 1992, the average price that publicly funded clinics paid for oral contracept ives rose 42%, for example.
Furthermore, many individuals who seek reproductive health care at family planning clinics often have other health care needs. In recent years, for example, the proportion of patients coming to family planning clinics in need of screening or treatment for STDs has increased dramatically. Forty percent of all medical visits to one Title X grantee in 1990 involved testing or treatment for STDs, compared with only 10% of visits in 1980. By 1993, STD and AIDS counseling, testing and treatment constituted, on average, 26% of the contraceptive services budgets among the agencies that offered these services.
Moreover, since clients of Title X-supported clinics frequently have no other source of health care, clinics must address patients' health needs more comprehensively, by offering such corollary health services as screening for diabetes or high cholesterol levels, programming on prenatal care or smoking cessation, and counseling on domestic violence or substance abuse. All of these efforts consume additional resources, in both staff time and money, usually without extra funding from any source.
Some providers cannot absorb these additional costs without cutting back on their patient populations. Others are forced to forgo routine testing and to base treatment on examinations alone. Still others must change the nature of their services, by requiring fees or taking a higher proportion of clients who can afford to pay. For poor women seeking to prevent unintended pregnancy—particularly many of those who may be leaving the welfare rolls in light of the 1996 welfare reform law—some of these changes could present insurmountable obstacles.
Despite growing enrollment in managed care plans nationwide, the need for the reproductive health services provided by publicly funded family planning clinics remains crucial for many low-income women, especially those who are uninsured. Even women who have some type of health care coverage continue to seek care at family planning clinics—whether or not those clinics are participating in managed care networks—because their plans do not cover the contraceptives they want or because of concerns about confidentiality.
Despite the continuing need for subsidized family planning services, some critics argue that Title X should be defunded entirely because it has failed to solve our national problems of unintended teenage pregnancy and out-of-wedlock births. Some even go so far as to claim that contraception itself is a failure, and that the provision of publicly funded family planning services has made these problems worse.
Yet incontrovertibly, contraception works: While no contraceptive, and no contraceptive user, is perfect, the fact remains that the 10% of American women at risk of unintended pregnancy who do not practice contraception account for 53% of all unintended pregnancies. Even the strongest supporters of the national family planning program readily admit that it will never, by itself, reduce the nation's unintended pregnancy rate to zero. Nevertheless, they also point out that the availability of affordable, voluntary family planning services remains the only programmatic intervention that—in a cost-effective manner—has a demonstrated ability to reduce unintended pregnancy, avert the need for abortion and improve birth outcomes and the overall reproductive health of women in the United States.
References
1. S. Ventura et al., "Trends in Pregnancies and Pregnancy Rates: Estimates for the United States, 1980-92," Monthly Vital Statistics Report, Vol. 43, No.11, 1995.
2. D.J. Jamieson and P.A. Buescher, "The Effect of Family Planning Participation on Prenatal Care Use and Low Birth Weight," Family Planning Perspectives, 24:214-218, 1992.
3. K.J. Meier and D.R. McFarlane, "State Family Planning and Abortion Expenditures: Their Effect on Public Health," American Journal of Public Health, 84:1468-1472, 1994.
4. S.D. Hillis et al., "The Impact of a Comprehensive Chlamydia Prevention Program in Wisconsin," Family Planning Perspectives, 27:108-111, 1995.
This report was written by Lisa Kaeser. Preparation was made possible by a grant from The General Service Foundation.
Major Sources
J.D. Forrest and R. Samara, "Impact of Publicly Funded Contraceptive Services on Unintended Pregnancies and Implications for Medicaid Expenditures," Family Planning Perspectives, 28:188-195, 1996.
J.J. Frost, "Family Planning Clinic Services in the United States, 1994," Family Planning Perspectives, 28:92-100, 1996.
J.J. Frost and M. Bolzan, "The Provision of Public-Sector Services by Family Planning Agencies in 1995," Family Planning Perspectives, 29:6-14, 1997.
S.K. Henshaw and A. Torres, "Family Planning Agencies: Services, Policies and Funding," Family Planning Perspectives, 26:52-59 & 82, 1994.
L. Kaeser, R.B. Gold and C.L. Richards, Title X at 25: Balancing National Family Planning Needs with State Flexibility, The Alan Guttmacher Institute, New York, 1996.
T. Sollom, R.B. Gold and R. Saul, "Public Funding for Contraceptive, Sterilization and Abortion Services, 1994," Family Planning Perspectives, 28:166-173, 1996.